State of Maryland

(Please retain the Instructions and a copy of your Wage Claim Form for your records)

READ CAREFULLY

WHO SHOULD FILE A WAGE CLAIM?

An employee who has worked in Maryland and believes an employer has unlawfully withheld the employee’s wages, including any bonus, commission, fringe benefits, overtime wages, or any other payment promised for service, may file a claim for unpaid wages on the attached Wage Claim Form.

Typically, there is a three (3) year statute of limitations under the Maryland Wage & Hour Law (MWHL) and/or the Maryland Wage Payment & Collection Law (MWCPL) for filing a lawsuit for unpaid wages in a court. (Note that federal wage laws may have different statutes of limitations for filing claims.) For the Maryland Department of Labor, Licensing and Regulation, Division of Labor and Industry, Employment Standards Service (ESS) to have sufficient time to investigate a claim for unpaid wages, ESS should receive an employee’s Wage Claim Form, along with any supporting documents, as soon as possible but in no event later than two (2) years from the date the wages became due.

Alternatively, instead of filing a wage claim with ESS, an employee may choose to bring a lawsuit against an employer for unpaid wages under the MWHL and/or the MWPCL with or without the assistance of a private attorney in a Maryland court. Please note that ESS, the Commissioner of the Division of Labor and Industry (Commissioner), and the Office of the Attorney General will not participate in any such action.

BEFORE FILING A WAGE CLAIM WITH ESS

Before filing your wage claim with ESS, you must first have asked the employer for your wages and been denied. To maximize your chances of recovery, you should send a written demand to the employer for payment of any wages claimed. You should keep a copy of any written demand and obtain proof of receipt by the employer, e.g., a certified mail receipt, an email receipt, an employer’s written response, etc.

TO FILE YOUR WAGE CLAIM WITH ESS

·  You must fill out and return the Wage Claim Form legibly and completely, and must sign the form under oath.

·  You must provide all known names (including corporate and trade names), addresses, phone numbers, and email addresses for your employer.

·  You also should attach to the Wage Claim Form the following documents that support your claim, if available: An employment contract and/or wage agreement, time sheets and/or a list of dates and hours worked, commission statements or other proof that commissions were earned, paystubs, employee handbooks, manuals or policy statements, business cards, and correspondence with an employer.

·  You must fill out, sign, and return the Wage Claim Authorization.

Note: In order to file a claim, you are NOT required to keep your own time records or have the documents above. These documents are being requested if you have them because they will help ESS better understand your claim and improve your chances of recovery.

WHAT TO EXPECT AFTER FILING YOUR CLAIM

After you file your wage claim with ESS, ESS will investigate your claim. ESS will assign an investigator to your claim who will contact your employer for information, and, if ESS needs additional information from you, the investigator also will contact you. If you get additional related documents, please mail or fax the documents directly to the investigator assigned to your claim. Once ESS completes its investigation, you and your employer will be notified in writing if the Commissioner will take action on the claim.

HOW THE COMMISSIONER CAN RESOLVE A WAGE CLAIM

Following an investigation of your claim, the Commissioner will determine whether the MWHL and/or the MWPCL have been violated. The Commissioner may try to resolve your claim in one of three ways:

1)  Informally through mediation;

2)  for claims under $3,000, by issuing an administrative order directing your employer to pay the unpaid wages the Commissioner has determined are due to you; or

3)  by asking the Office of the Attorney General (OAG) to bring a lawsuit for unpaid wages on behalf of the Commissioner to your use and benefit against your employer in a Maryland court.

Please note: (1) the OAG is not required to file a lawsuit and may decline to accept the case; (2) acceptance of a wage claim by ESS, the Commissioner, and/or the OAG does not guarantee collection of unpaid wages; and (3) under the MWCPL, an employee may not knowingly make to a governmental unit or official a false statement with regard to any investigation or proceeding under the MWPCL with the intent that the government unit or official consider or otherwise act in connection with the statement. An employee who does so may be charged with a misdemeanor and, on conviction, is subject to a fine not exceeding $500. In addition, if an employee provides false or inaccurate information or fails to cooperate, the Commissioner may decline to take any action or may cease taking action.

Please mail your completed and signed Wage Claim Form, Wage Claim Authorization, and any supporting documents to:

EMPLOYMENT STANDARDS SERVICE

1100 N. EUTAW STREET, ROOM 607

BALTIMORE, MARYLAND 21201

For Office Use Only: Reference Claim #

SECTION A. Personal Information

Name:

First Middle Last

SSN or ITIN, if available: - -

Address:

Street City State Zip Code

Daytime Telephone: Email Address:

*If you change your address, email address, or telephone number after submitting this form, notify Employment Standards Service (ESS) immediately in writing. If ESS cannot contact you, your claim will be dismissed.

Driver’s License #: State of Issue:

Date of Birth: Gender: M F Other:

*Race (choose all that apply): American Indian or Alaska Native Asian Black/African American Hispanic or Latino Native Hawaiian or Other Pacific Islander White

*This information is collected for statistical purposes only.

SECTION B. Employment Information

*Please list all known names (including corporate and trade names) addresses and telephone numbers.

Employer Name: Telephone:

Employer’s Trade Name (if any):

Employer’s Address: Street City State Zip Code

Owner’s Name, if known: Phone:

Owner’s Address, if known:

Street City State Zip Code

Supervisor’s Name, if known: Phone:

Supervisor’s Address, if known: Street City State Zip Code

Supervisor’s and Owner’s License Plate or other identifying information, if known:

Type of Business: Job Position/Title: (Example: retail, restaurant, construction, etc.) (Example: office worker, carpenter, etc.)

First date of work: Last date of work: Number of days worked each week:

Number of hours worked each day: Next scheduled payday is:

Rate of pay: $ per: Day Hour Week Month Year Commission

Frequency of pay: Daily Weekly Bi-Weekly Monthly Bi-Monthly

I was: Fired Laid-Off Quit Other I am still working there number of days per week.

SECTION C. Eligibility

SECTION D. Type of Wages Owed

SECTION E: list all dates and hours (Month/Day/Year) worked for which you were not paid.

Use additional paper if needed.

SECTION E SUBTOTAL: $

SECTION F: Commission, Bonus, Piece Rate, or Flat Rate

Complete this section if you claim unpaid commissions, bonuses, piece rates, or flat rates. Attach any evidence, including commission, bonus, piece rate, or flat rate agreements, or explain in detail how these wages were earned.

SECTION F SUBTOTAL: $

SECTION G: Unauthorized deductions

Complete this section if you claim your employer deducted money from your wages that you did not authorize. List each deduction and attach copies of your paystubs reflecting the deduction if possible. Use additional paper if needed.

SECTION G SUBTOTAL: $

SECTION H: Fringe Benefits

Complete this section if you claim you are owed wages for unused vacation, sick leave, paid time off (PTO), holiday leave, or personal leave hours. If possible, attach a copy of your paystub or other document showing the accrued but unused hours.

SECTION H SUBTOTAL: $

SECTION I: Mileage REIMBURSEMENT

Complete this section if you claim you are owed mileage reimbursement. Use additional paper if needed.

Mileage reimbursement rate: $______per mile. Normal roundtrip commute is ______miles.

SECTION I SUBTOTAL: $

SECTION J: Business Expenses

Complete this section if you claim you are owed for business expenses, other than mileage reimbursement. Identify each business expense you are claiming and attach receipts. Use additional paper if needed.

SECTION J SUBTOTAL: $______

Section K. LIST BELOW THE SUBtotalS claimed for Sections E through J:

PLEASE READ AND SIGN THE CERTIFICATION AT THE BOTTOM (This page and the Wage Claim Authorization following this page must be signed)

I. ADDITIONAL INFORMATION: If you have any additional information about your claim, provide it below. Use additional paper if needed.

I hereby certify, under the penalties of perjury, that all of the statements I HAVE MADE ON THIS WAGE CLAIM FORM are true.

Signature: ______Date: ______(Original signature required, no photocopied signature accepted)

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WAGE CLAIM AUTHORIZATION

I understand that once my claim is investigated, the Commissioner will determine whether there has been an apparent violation of the Maryland Wage and Hour Law (MWHL) and/or the Maryland Wage Payment and Collection Law (MWPCL) by my employer/former employer (employer). If the Commissioner determines the MWHL and/or the MWPCL have been violated, I consent to the Commissioner resolving my wage claim:

1)  Informally through mediation;

2)  if my claim is less than $3,000, by issuing an administrative order directing my employer to pay my unpaid wages under the MWPCL; or

3)  by asking the Office of the Attorney General (OAG) to file a lawsuit on behalf of the Commissioner to my use and benefit in a Maryland court of proper jurisdiction under the MWPCL. I understand the OAG is not required to file a lawsuit and may decline to accept the case. I also understand that acceptance of my claim by ESS, the Commissioner, and the OAG does not guarantee collection of my unpaid wages.